With the government putting off ‘externalisation’ of commissioning support until 2016 and with CCGs anecdotally being encouraged not to look beyond the NHS offering, because of the potential redundancy bill, the commissioning support market has largely yet to emerge.
Some independent support providers are working with CCGs - so far on a relatively small scale - but for the most part, CCGs are buying services from the 23 NHS local commissioning support units licensed by the NHS Commissioning Board that have been set up around the country. We asked commissioning experts how CCGs should approach commissioning support, given the landscape they face
1. Be clear about what you want
As managing director of two commissioning support units covering 11 clinical commissioning groups and 3.5 million people, David Stout is in no doubt about the best way for CCGs to approach commissioning support: work your commissioning goals out carefully.
’The clearer CCGs can be about what they are trying to achieve - what they are aiming at - the better. That will enable CSUs to respond. My advice is to share your aspirations with your CSU, then they can help you work out what it is you need from them.’
But working out what you want is harder than it seems for CCGs because they are in uncharted territory and ‘don’t know yet what they don’t know’.
’Knowing what you need has been a long-standing problem’, says Chris Naylor, fellow in health policy at the King’s Fund - which examined commissioning support for PCTs, two years ago. ‘It´s a matter of people not knowing what they don´t know. It makes it difficult to work out what to outsource.
’Currently, there may be good reasons for that. There was a survey out in the first part of last year which suggested that a lot of CSU leaders didn´t feel CCGs had the information they needed to choose their support. And over the last six to twelve months, authorisation has been a pre-occupation. Even although plans for commissioning support were assessed as part of that, CCGs´minds have been focused elsewhere.’
Georgina Craig, who runs an independent commissioning support consultancy advises CCGs to differentiate between the things that add value for the CCG in terms of relationship management and engagement and those that don´t.
’Commissioning support is only valuable in that it helps CCGs do what they will be held accountable for by the NHS Commissioning Board. For the other things, back office stuff and the like, it makes no difference who does them so it doesn´t make sense for CCGs to take them on.
Dr Johnny Marshall, interim partnership development director at NHS Clinical Commissioners agrees that CCGs need to work out the things they and only they, can do. But CCGs also need to keep in mind possible economies of scale.
’At the centre should be the core relationships that will drive the financial ones. But the other key thing is working what out might work better at scale than in-house.’
2. Make friends with your commissioning support providers
Georgina Craig believes CCGs should ‘insist’ on having dedicated, named people in their CSOs to work with.
‘Especially if they are parting with a significant part of their commissioning support budget and ideally, the commissioning support staff should sit within the CCG so that they absorb your culture rather than that of the CSO.’
Chris Naylor agrees with the importance of fostering good relationships with CSOs but points out that the nature of prior relationships will impact on how those relationships pan out. ‘Previously difficult or negative relationships with PCTs may make the CCG want to look elsewhere - particularly where CSUs are led by the same people.
’CSUs typically have a much wider patch than PCTs did, so may have personal relationships with some CCGs in the patch but not others. Other CCGs may be alien and it will take time for the CSU to become familiar with their needs. That will affect relationships and will be one of the key challenges in the medium term.’
Dr Marshall argues that the responsibility for those relationships rests equally with the CSOs. ‘If you turn it around,’ he says, ‘It´s very important that the CSO is building its customer base. CSOs need to ensure that they are building a relationship with CCGs and understanding customer need.’
3. Shop around
CSUs won’t leave the NHS until 2016. But until this ‘externalisation’ – as this departure is being described – CCGs have the option to shop around now, though in practice they do have to take into account potential redundancies this might incur.
Nevertheless there is a small but growing group of independent providers.
And although it has started off in a relatively circumscribed way, the market for commissioning support will evolve quickly, experts believe.
’There´s definitely a developmental element to it at the moment’, says Dr Marshall. ‘It remains to be seen whether we need as many CSUs as we currently have to get the benefits of scale. Over the next four to five years there´s likely to be a lot of flux over arrangements.
’However, at the moment, while most CCGs are aware of what their local CSU has to offer, I doubt if many know what others are doing.’
‘A lot could happen before 2016 - including a general election,’ says Chris Naylor. ‘It´s all still up for grabs and what the scene will look like by then is uncertain. There´s plenty of scope before then for mergers. The number of externalised CSUs could be a lot fewer. There could also be hybrid arrangements too.’
’There´s a wide variation in what CCGs are spending on commissioning support at the moment, which reflects the different approaches of CCGs. There is actually a three way split - build, buy or share. CCGs are very often building some services in-house, buying bits from the CSU and sharing functions with other neighbouring CCGs.”
4. Remember the customer is king
The emerging market for commissioning support is customer- rather than supplier-driven, David Stout says. ‘CCGs are looking beyond the common offer for what suits them - and our job is to be ready for that.’
Georgina Craig believes a ‘buyers market’ in commissioning support means CCGs should expect CSOs to go the extra mile. ‘Expect them to go way beyond the call of duty for you,’ she advises. ‘CCGs should expect outstanding customer service. If you find yourself having conversations about small points of principle with your CSO, it´s time to look elsewhere.’
Mr Stout, who leads the CSUs in Hertfordshire and Essex points out that individual CSUs will evolve with customer demand, eventually offering a wider range of services in response to CCGs needs. ‘With things like service redesign down the road, things are only going to get harder and harder for CCGs. As they get to grips with these issues, they are going to need support in such things. We - the CSUs - need to prepare ourselves too and be flexible.’
5. Drive a hard bargain
Build flexibility and a focus on outcomes into your contracting, Georgina Craig advises. That phrase again: ‘We don´t know what we don´t know about the new commissioning, it´s a moveable feast, so make sure you are covered for all eventualities.
’Also look for value-adds for your CCG that cost the CSO nothing. If they are doing work for other CCGs that you think might be of value for you, ask them to share it with you.’
David Stout agrees contracting is crucial for CCGs and believes this too will evolve quickly. ‘Most CSU service level agreements have operational targets built in and outcomes-based measures can be built in going forward There is also the notion of moving towards a gain-sharing approach. If you succeed together, you share the gains and vice versa if you fail.’
However, Chris Naylor questions whether individual CCGs can be strong enough to hold CSUs and others to account. ‘The hand off between CCGs and CSUs could be a potential blind spot for some CCGs. It already varies in practice. Some CCGs are good at it already. When PCTs were buying commissioning support, a lot were getting into outcomes-based contracting. Some had risk-sharing arrangements. PCTs were definitely starting to move in that direction and I could imagine that CCGs will go that way too.’
6. Get involved in feeding back
’We are looking for feedback from individual CCGs about individual services,’ says David Stout. Also, in Essex, we get collective feedback from all the CCGs collectively on our performance, so we can build up a picture of how we´re doing overall and adapt.
’My advice to CCGs is to be honest with your feedback - both good and bad. Come forward and say what´s going well and what´s not.’
Chris Naylor identifies a cultural challenge for CSUs and suggests that CCGs can help them adapt through appropriate feedback. ‘We are talking about a large number of people in CSUs moving from a leadership mindset to a customer-support mindset and that´s another big challenge for them,” he says.
7. Don´t forget about your own organisational development
David Stout says CCGs do need to look at how they want to develop as organisations and to remain flexible. ‘They might move towards taking on more or less support work themselves in the future. It could go either way’, he says.
’The bigger they are to start with, the more they can do - whereas some CCGs want to be lean, clinically-led outfits that outsource everything. So as CSUs, we know we will need to be incredibly flexible to allow for that.’
Georgina Craig agrees: ‘Have a clear vision for your own organisational development. Align your organisational plans with the things that add value to your CCG - your relationships with providers and patients. It´s dangerous to invest too much in the CSU and miss the chance to develop relationships yourself. Commissioning is a change-management process. Be careful of what you outsource. You need to be aware of building capacity and capability in-house.’
’Take a long-term view. Realise that how you set yourself up will affect your ability to be a great CCG in three to four years’ time.’
8. Be cautious about tendering
As the market develops for commissioning support, CCGs will increasingly have to compare offerings and put support services out to tender.
But while CCGs understandably want to benchmark CSU services, says David Stout, they should bear in mind that it is actually a very difficult thing to do.
’It´s very hard to compare like with like. What CSUs do can vary a lot from place to place. CCGs need to be aware that this makes benchmarking very difficult.
’And if they are thinking of tendering for support services, they need to make sure the benefit is worth the effort. It´s quite legitimate to test the market if you have a strong sense that you´re not getting value for money - but it can be fraught.’
9. Bear in mind you can renegotiate
David Stour also advises that CCGs need to be pragmatic about what they will eventually need from their CSU.
‘For example, you might have decided to do something in-house that you wish you hadn´t. I see it as a long-term thing. 80% might be right and 20% wrong first time off. But you can renegotiate either at the next contract renewal or if there is some wiggle-room built into to the contract if for example you want to pass stuff over.’
Dr Marshall advises that contracting for commissioning support over a shorter term such as 18 months is a good idea. ‘I would counsel caution over signing up for years without some sort of room for renegotiation.’
’Think creatively about who else can offer you commissioning support,’ advises Georgina Craig. ‘For example, providers have loads of data that can be useful to CCGs. Rather than just asking them for it, or relying on your CSU to feed it back to you, pay for someone from your CCG to sit in with the provider looking at the data and providing commissioning support to your CCG in that way. Think of secondments, barter deals.’
Chris Naylor describes a King’s Fund round table on commissioning support last year: ‘A lot of people asked where the innovation would come from because the reforms seemed to be delivering largely a lot of new structures.
’The answer is that CCGs need to use CSUs to do things differently. Ideally, we want commissioning support to be something that becomes a catalyst for change, enabling CCGs to break new ground,’ he says.
Alisdair Stirling is a freelance journalist